Abstract
Crisis resolution and home treatment (CRHT) teams have been introduced into mental health care in the UK because, in general, patients do not want to be admitted to hospital, treatment at home is cheaper and in the only randomized controlled trial conducted so far there was no difference in symptomatic outcome. However, because of compulsory gate-keeping by CRHT teams, some patients no longer have the option of going to hospital if they want to. This aspect of the introduction of CRHT teams has not been discussed so far, but it certainly warrants further examination. Intervention through CRHT teams may in fact increase compulsory admissions and serious and untoward incidents, although this is not certain. Sufferers from psychosis are the patient group most likely to be compulsorily admitted to hospital and they are generally considered less responsible for serious and untoward incidents. Therefore, a possible solution could be to offer a choice to some patients, namely those with a psychotic disorder, on whether they want to be admitted or not. At least one should investigate what the consequences of this policy would be, if it were to be adopted in a test region. This example shows that in developing policies for rationing health care, it can be important to look at subgroups and not just at average results when determining the best course of action.
Introduction
There are insufficient resources available for mental health services to offer every treatment that a patient may request. Rationing is unavoidable and takes place at nearly every level of service. The government determines which treatments should be offered and local mental health professionals have to decide which patients are eligible and provide the interventions. It is difficult to make rational decisions about rationing, but it is important to use the best factual information available. 1 Following Daniels, 2 one can make a distinction between services that have to be provided and services about which rational people can disagree whether or not they should be provided, and this disagreement can relate to unknown factual information or disagreement about values involved.
Crisis resolution and home treatment (CRHT) teams were introduced in the UK as an alternative to admission to a psychiatric hospital. However, for the somewhat less severely ill patients, the option of going into hospital voluntarily has been taken away. There has been no public debate about this, but it does raise important questions, as this paper makes clear. Even without looking at specific details of particular cases, 3 there are many ethical controversies relating to CRHT teams in general and gate-keeping in particular which have not so far been discussed.
CRHT teams
Patients with mental health problems sometimes need care urgently and mental health services have to provide care in emergency situations. Inpatient treatment is quite expensive and patients generally prefer to be treated at home. 4 That is why CRHT teams were introduced to the UK 10 years ago. CRHT teams care for mental health patients for a limited period (usually a few weeks) and then refer them to another service, such as their community mental health team or their general practitioner. 5 The aim of CRHT teams is to offer a less expensive alternative to admission to hospital for patients with severe mental illnesses such as schizophrenia. (Although the official name is crisis resolution and home treatment team, it is in practice often abbreviated to home treatment team.)
Home treatment is offered instead of hospital admission, and CRHT patients are suffering from serious mental health problems, otherwise admission would not be considered. However, patients have to agree to the involvement of the CRHT team and they should have the capacity to decide this. A In practice, clinicians might overestimate the capacity of patients to decide for themselves; at least there is empirical evidence that it happens on wards and in the community. 6 It has not, however, been investigated for CRHT team patients.
Patients of CRHT teams tend to suffer from psychotic disorders, mainly schizophrenia, affective disorders such as depression and bipolar disorder, and personality disorders. The treatment offered by CRHT teams consists of daily or twice-daily visits with 24-hour telephone support, prescribing and administering medication, practical help with meals, help with organizing finances and benefits and emotional support to patient and carers. The actual treatment varies according to the clinical needs of the patient. The Mental Health Policy Implementation Guide 5 provided detailed guidelines for the introduction of CRHT teams, but the guidelines were not compulsory. The service that CRHT teams can offer therefore differs from borough to borough and is dependent on local funding arrangements and the capacity of pre-existing services. 7
Despite local differences in CRHT team operations, some activities are mandatory. All teams must perform gate-keeping, i.e. no patient should be admitted to hospital unless they have had face-to-face contact with a member of staff of the CRHT team and the team has agreed with the admission to hospital. In the UK, Monitor, the government organization that checks the requirements for foundation trusts, expects a 95% compliance with face-to-face gate-keeping. 8 Because there are strict requirements from Monitor, there is no room for making different arrangements locally, let alone that individual health practitioners can decide not to do gate-keeping. It is an example of rule-based rationing by the government, 9 but the rationing occurs indirectly. Monitor does not forbid admission to hospital of certain categories of patients. However, CRHT teams tend to be funded by reduction in hospital beds and there is huge pressure on them not to admit too many people, so gate-keeping does result in fewer admissions to hospital.
One of the philosophies behind the introduction of gate-keeping was that nobody should be admitted to a psychiatric hospital unnecessarily and that assessment by a member of a CRHT team could prevent this by supporting patients who do not wish to be admitted. However, there are patients who prefer to go to hospital. Patients with mental health problems, who would have been admitted 10 or 15 years ago, are no longer offered admission, even if they prefer to be admitted. Gate-keeping has reduced patients’ choice, but this was never discussed in a public debate and the arguments for and against it need to be examined.
Arguments in favour of gate-keeping
There are many reasons why patients should not be offered the choice of going to hospital but only offered CRHT. Generally patients tend to prefer to be treated in the community 4 and there is evidence for the effectiveness of CRHT in the UK. There has also been one randomized controlled trial showing that, with CRHT, inpatient bed use could be reduced and that the outcome in terms of symptoms and patient satisfaction was similar to hospital admission. 10 Furthermore, CRHT was less expensive to provide. 11
If CRHT services are less expensive and the outcome is similar, it is an acceptable approach for the government to ask local mental health services to offer this service but potentially also to make it compulsory, removing the element of free choice, as CRHT teams do save money via a reduction in inpatient bed use. However, the current available evidence is not so clear-cut if one investigates it more thoroughly by looking at subgroups 12 and not only at the averaged data.
Arguments in favour of patients' choice
There are a number of arguments in favour of patients’ choice instead of gate-keeping. These include respect for patient or carer preference, the fact that some patients are still admitted after a few days’ CRHT and a possible increase in compulsory admissions and serious and untoward incidents. All these points, but especially the latter two, could be seen as arguments for offering people with a psychotic disorder freedom of choice.
Patient preference
Although, prior to the introduction of CRHT teams, patients tended to prefer to be treated in the community, 4 there will always be a particular patient who prefers to be admitted to hospital. Surveys regarding patient preference for being treated at home were conducted prior to the introduction of the CRHT teams and it is not entirely clear what respondents had in mind when they were asked about being treated in the community. With home treatment, patients are visited up to twice a day and they might experience this as quite intrusive. Neighbours might notice people wearing badges ringing their doorbell. Family or friends (or even the plumber) might be there when the CRHT team is coming, which can be upsetting if they do not know that somebody is under the care of the CRHT team. Some patients might like to be away from home, especially nowadays because the quality of inpatient wards has improved in the UK with, for example, single rooms more and more becoming the norm. It is, however, not unreasonable to offer the cheapest option first, if the outcome is roughly the same. This is also happening in physical health care.
Carer's preference
When CRHT teams were initially developed, research findings suggested that carers preferred CRHT. 13 However, according to a more recent qualitative study, CRHT can be stressful for other family members, especially young children. 14 In an Australian study, approximately half of the carers of people in home treatment would have preferred them to be admitted to hospital. 15 No recent quantitative data from the UK are available. One could still argue that in times of austerity, family and carers have to accept CRHT, if the outcome is similar to hospital admission, even if they would prefer their family member to go to hospital, but the argument is less convincing than when it is only a patient's preference.
Health services, including CRHT teams, cannot demand that family members or carers offer more support, but family members and carers might feel pressured into offering it. In practice, most family members and carers are happy to give more help, even though they are not obliged to do so, but there is the risk that they become overburdened. This is certainly an area where more empirical data are necessary, but somewhat similarly to a possible overestimation of decision-making capacity, this is not a unique situation for CRHT teams. Before the introduction of compulsory gate-keeping there was no obligation to consult family and carers for voluntary admissions and the risk of overburdening carers existed then as well. In England, the nearest relative has to agree to the longer compulsory admission (section 3 Mental Health Act), although they can be displaced. In many other European countries, for example the Netherlands, a family member does not have that legal power, so family members have no legal influence at all regarding admission to hospital.
Admission only postponed, not avoided
There are patients who are initially treated by a CRHT team but for whom home treatment is not successful. In one naturalistic follow-up study, 62 of 293 patients (21%) had to be admitted to hospital after a median CRHT team period of 11 days. 16 It is difficult to predict for which patient CRHT will be sufficient and who will still need to be admitted to hospital after an initial period of CRHT. 17 Home treatment teams save bed days on average but for a considerable number of patients admission is only postponed, not prevented.
Is this approximately 20% deferred admission to hospital rate sufficient reason to offer free choice and to not make CRHT compulsory? Patients might be dissatisfied that they were admitted after a week or so of CRHT, but first attempting a less expensive treatment option can be acceptable if the overall outcome is similar. In common with other branches of medicine, the decision by policy-makers to offer the cheapest option first, and no treatment choice, is dependent on how one values the prolonged period of illness and how long the period with the cheaper treatment actually lasts. Although some people do not like CRHT, it is not particularly painful or dangerous, so it is not so bad that people cannot be pressured into having it. If it is not successful it will last only one or two weeks, not months. Therefore, the fact that approximately 20% of the CRHT team patients are eventually admitted to hospital is, on balance, not a decisive argument against compulsory gate-keeping.
Risk of compulsory admissions and untoward incidents
As stated before, in the only randomized controlled trial conducted to date, the outcome between CRHT and hospital treatment was roughly similar in terms of symptoms and patient satisfaction. 10 There was an increase in serious and untoward incidents (such as suicide and criminal offences) in CRHT team patients in the randomized controlled trial, but this was not statistically significant. These serious and untoward incidents are relatively rare and the randomized controlled trial had insufficient power to detect a statistically significant difference. A few non-randomized studies have suggested an increase in both compulsory admissions and serious and untoward incidents after the introduction of CRHT teams. 18 However, the empirical evidence is not conclusive, because huge variation in services makes the results difficult to interpret. 7 From a clinical perspective it is plausible that compulsory admissions and serious and untoward incidents increase with introducing CRHT teams. It could well be that by postponing admission to hospital some patients become more unwell and, while initially they might have agreed to a voluntary admission, they need a compulsory admission after CRHT has been attempted. People becoming increasingly unwell at home could also increase the number of serious and untoward incidents.
While the evidence for an increase in serious and untoward incidents and compulsory admission is not strong, the consequences can be quite severe and compulsory admissions to hospital can be very traumatic for patient and family; this is also the case with serious and untoward incidents. Therefore, the risk of compulsory admission and serious and untoward incidents is an argument against compulsory gate-keeping.
Why was compulsory gate-keeping not discussed before implementation?
It is surprising that the question of taking away patient choice for those who prefer admission has not been discussed in the literature. Some other important issues have not been investigated either, such as decision-making capacity in CRHT team patients’ and carers’ views, but these issues are not unique for CRHT teams.
One possible reason that compulsory gate-keeping was not discussed is that in mental health care in England there are many different specialized teams and it is not immediately obvious for people not working in the field what happens in every service, in other words it is difficult to get hold of the relevant facts. 1 Probably, there is also the tacit assumption that nobody wants to go to hospital. However, some people do prefer to go to hospital – for example, if they were able to go to hospital for a similar condition 10 years before. The risk of compulsory admission and serious and untoward incidents is more a statistical risk than an identified risk in a particular patient and this might also be a reason for lack of attention to the problem. Psychological research suggests that in psychological experiments people are more willing to help a single identifiable victim, 19 but this is not justified from a moral point of view. 20 Possible infringements of patients’ autonomy are not being widely discussed in other areas of medicine as well, such as organ donation without explicit consent and preoperative testing for pregnancy in teenagers. 21 However, this is an unwanted situation and this paper aims to open the discussion about ethical aspects of CRHT teams.
Proposed solution
Increased chance of serious and untoward incidents and compulsory admissions are the main concerns of compulsory gate-keeping. It tends to be the patients with psychotic disorders who are admitted to hospital against their will. If somebody with a psychotic disorder commits a crime, he or she is either considered not guilty because of lack of criminal intent or considered to have suffered mitigating circumstances and is likely to receive a less harsh punishment. Irrespective of whether one accepts that rational suicide is possible, 22 it is not rational suicide if somebody kills himself while psychotic. Therefore, if home treatment is unsuccessful and patients have to be admitted to hospital, psychotic patients have to bear the most serious consequences. Although mainly for financial reasons it is not desirable to offer a free choice to everybody, one could still consider offering a choice to patients who are psychotic.
The primary reason for considering the offer of free choice to psychotic patients is not financial, but to avoid compulsory admissions and to protect people from harming themselves and others. Empirical evidence is lacking, however. It is currently unclear whether offering free choice to people with psychotic disorders would dramatically increase costs, because it might reduce the number of unsuccessful treatments with CRHT teams. One could offer free choice for psychotic patients in a certain region and investigate whether costs would increase and/or compulsory admissions and serious and untoward incidents decrease.
Summary and conclusions
It is beyond dispute that one should continue to offer CRHT team services for mental health patients who want to be treated at home instead of being admitted to hospital. The symptomatic outcome is roughly similar and CRHT teams are less costly.
The question is whether patients should be offered a choice and be offered the opportunity to go to hospital if they prefer that. This problem warrants further debate. The limited evidence suggests an increase in compulsory admissions and serious and untoward incidents with CRHT teams. This is mainly an issue for psychotic patients, who are more likely to be admitted against their will and more likely to harm themselves or others. Offering patients a choice could be an option for psychotic patients, or at least this option should be further empirically investigated. One could start it in a certain region and see what happens in terms of overall costs, number of compulsory admissions and number of serious and untoward incidents. Currently, rational disagreement 2 about this proposed solution is still possible as one might not accept the limited factual evidence and/or value the risk of compulsory admission and/or a serious and untoward incident differently.
Discussing this problem in greater depth has also clarified an issue within the general debate on resource rationing. A decision-maker needs to look very carefully at the available factual evidence, 1 not only at the general evidence, but also at the evidence for specific subgroups. 12 If the government wants to make strict rules and not make allowances for local arrangements and judgement of clinical practitioners, 9 it is important that the rules are quite specific, as this example illustrates; only looking at averaged findings might be an insufficient basis for sound decision-making.
Footnotes
A
In England patients can have home treatment without their consent after they have been compulsorily admitted to hospital under a section of the Mental Health Act. The Responsible Clinician can grant section 17 leave from hospital and attach conditions to it such as that they will take medication as prescribed and be compliant with CRHT team visiting arrangements. If patients are not compliant with section 17 leave arrangements they can be recalled to hospital. This is not further discussed in this paper.